Smiles For Tomorrow

Prashant Gagneja, DDS, MS

Continuing Education Units: 4 hours

This continuing education course is designed for general dentists, dental hygienists, pediatricians, family practitioners, dental assistants, nurse practitioners and office managers. The topics reviewed include: normal oral structures; common oral conditions; eruption patterns; dental caries and prevention; and orofacial trauma. Upon completion of this course the user will better understand appropriate evaluation, treatment, and preventive measures that should be instituted during infancy and continued on a regular basis to maintain optimal health.

Overview
A childs oral health is an integral part of overall health. Appropriate evaluation, treatment, and preventive measures should be instituted during infancy and continued on a regular basis to maintain optimal health. This presentation is designed to offer practical pediatric oral health information and has been developed in cooperation with the American Academy of Pediatric Dentistry. Topics in this presentation include: Normal Oral Structures Common Oral Conditions Eruption Patterns Dental Caries and Prevention Orofacial Trauma These topics were selected to provide the background necessary to offer advice on a variety of conditions and to encourage early referral to the pediatric dentist.

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Learning Objectives
Upon the completion of this course, the dental professional will be able to: Better understand appropriate evaluation, treatment, and preventive measures that should be instituted during infancy and continued on a regular basis to maintain optimal health. Discuss the common oral conditions (common acquired conditions, developmental conditions, and congenital conditions) of the pediatric patient. Explain the eruption patterns of the pediatric patient. Discuss the caries process which includes etiology and transmission, patterns of decay, caries risk assessment, and anticipatory guidance. Describe what to do for orofacial trauma in the pediatric patient.

Course Contents
Introduction Normal Oral Conditions Common Oral Conditions Developmental Conditions Congenital Conditions Eruption Patterns Dental Caries and Prevention Orofacial Trauma Course Test References About the Author

Normal Oral Conditions

Frenum Thin folds of mucous membrane can be seen at the midline of the upper and lower lips when the lips are retracted. These folds of tissue are the superior labial frenum and the inferior labial frenum.

Introduction
To begin this discussion, we will first look at some of the oral structures and associated conditions that may be noted during the examination.
Normal Frenum

Diastema A diastema is considered normal in the primary and mixed dentition as part of normal dental development.

Normal Oral Structures

Discussed in this section are the following normal oral structures: Frenum Buccal Mucosa Tongue Gingiva Alveolar Mucosa Masticatory Mucosa Palate Tooth Form

Diastema during primary dentition

Diastema during mixed dentition

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A diastema, or space, between primary or permanent central incisors is often associated with, though not necessarily caused by, a prominent superior labial frenum. [The diastema can also be caused by an unerupted supernumerary, or extra tooth. A diastema persisting after eruption of the permanent canines (ages 10-13) should be evaluated for treatment options such as a frenectomy and/or orthodontic treatment.]

Cheek Bite

Chronic Cheek Biting

Diastema in an Eight-month-old

Buccal Mucosa The buccal mucosa covers the inner surface of the cheeks. Stensens duct, the opening for the parotid gland, is located opposite the maxillary molars. Saliva from the parotid gland is secreted through this opening and comprises approximately 25% of the total resting salivary volume. Many common childhood infections like Measles and Chickenpox show early signs of disease in the oral mucosa.

the floor of the mouth is a fold of tissue called the lingual frenum. At the base of the frenum attachment on the floor of the mouth are small, bilateral elevations known as the sublingual caruncles, duct openings for the sublingual and submandibular salivary glands.

Tongue: Ventral Surface

Buccal Mucosa

Fordyces Granules are normal ectopic sebaceous glands found on the upper lip, buccal mucosa, retromolar area and anterior tonsillar pillar. They present as multiple yellow or whitishyellow, slightly raised, tiny pinhead-sized spots. Once the teeth have erupted, trauma from cheek biting is often seen in the buccal mucosa. Tongue - Ventral Surface Elevation of the tongue reveals the ventral surface. Extending from the ventral tongue to

Short Lingual Frenum

TongueDorsal Surface The dorsal surface of the tongue is covered with four types of papillae. Filiform are the most numerous papillae and cover the anterior twothirds of the dorsum of the tongue. Although these papillae have no taste function, they may serve a tactile function. There are four basic taste sensations: sweet, salt, sour, and bitter. Specific regions of the tongue have specific

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Pigmented Pediatric Gingiva Dorsal Surface

associations with these sensations. The data is incomplete, but its been shown that generally the tip of the tongue has receptors for sweet and salty sensation, and sour and bitter receptors lie near the back. Fungiform papillae are singular knoblike projections scattered among the filiform papillae and may appear redder than the area around them. Circumvallate papillae are large, mushroom-shaped elevations that form an inverted V separating the anterior two-thirds from the posterior one-third of the tongue. Foliate papillae are found on the lateral border of the tongue in the region of the circumvallate papillae and appear as parallel slits. Gingiva The gingiva is divided into two distinct zones: free gingiva and attached gingiva. The free gingiva surrounds the tooth forming a sulcus (or crevice) next to the tooth. On the facial surface of the gingiva, a shallow depression called the free gingival groove separates the unattached gingiva from the attached gingiva. The attached gingiva is firm and tightly attached to the underlying alveolar bone. The width of the attached gingival is greater in adults than in children.
Normal Gingiva in Mixed Dentition

Alveolar Mucosa The alveolar mucosa is contiguous with the attached gingiva. The alveolar mucosa is not attached tightly to the bone. The alveolar mucosa is shiny and not stippled. It is more reddened by the underlying blood vessels and thinness of the mucosa. Small blood vessels may be visible. In the maxillary arch, the palatal gingiva does not change into alveolar mucosa but remains contiguous with the masticatory mucosa of the hard palate.

Alveolar Mucosa: Facial Aspect

Masticatory Mucosa The attached gingiva and hard palate are covered by masticatory mucosa. These tissues are parakeratinized or keratinized to withstand the forces of mastication.

Gingiva

In a healthy state, the gingiva has a stippled appearance. It is also pale pink and free of bleeding. The color of the gingiva varies by the degree of vascularity, epithelial keratinization, pigmentation and thickness of the epithelium. 4

Masticatory Mucosa: Palatal Aspect

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The Palate The transverse ridges, located at the anterior portion of the hard palate, are known as the rugae. A bulge of tissue at the midline, lingual to the central incisors, is the incisive papilla. Both the rugae and incisive papilla are susceptible to traumamainly burns from hot food. Treatment is palliative and usually involves avoiding further insult to tissues until healing is complete.

The torus palatinus is a benign bone overgrowth that may be noted in some individuals at the midline of the hard palate. Torus palatinus is rarely seen in children younger than age 14. Tooth Form Compared to permanent teeth, primary or deciduous teeth are smaller but have a more squat and bulbous appearance. The enamel of primary teeth is whiter, the dentin is thinner and the pulp chamber is proportionately larger. The enamel of permanent teeth has more yellow, brown, or gray tones.
Tooth Form

Normal Hard Palate

Primary Teeth

Trauma to Hard Palate

The soft palate extends posteriorly from the hard palate. The descending pendulum of tissue from the midline of the soft palate is the uvula. Immediately posterior to the hard palate, at the junction of the soft palate, are the palatine fovea, which are small pits or depressions at the midline.

Permanent Teeth

Common Oral Conditions

Common oral conditions seen in the pediatric patient will be our next area for discussion. These conditions are divided into three broad categories: Common Acquired Conditions Developmental Conditions Congenital Conditions

Junction of the Hard and Soft Palate

Discussed in the first of three sections are: Common Acquired Conditions: Candidiasis Glossitis Primary Herpetic Gingivostomatitis Recurrent Aphthous Ulcer Discolored Teeth
Soft Palate and Uvula

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Candidiasis The pseudomembranous form of candidiasis is characterized by raised, white, curd-like plaques that leave a raw bleeding surface when scraped. Candidiasis often occurs in children with chronic conditions who are on long-term antibiotic therapy as well as in children who are immunosuppressed. The patient may be asymptomatic or may complain of a sore throat if the esophageal tissues are involved. In the newborn, secondary infection may occur. Lesions may be found on any mucosal surface. Topical or systemic antifungal agents are the treatment drugs of choice.

and is characterized by painful, erythematous, and swollen gingiva. Multiple tiny vesicles first present on the perioral skin, vermillion border of the lips and the oral mucosa. The vesicles soon rupture into large, painful ulcerated areas.
Primary Herpetic Gingivostomatitis

Extraoral

Intraoral

Candidiasis

Systemic symptoms of fever, malaise, and cervical lymphadenopathy typically occur first, followed by the appearance of vesicles that progress to ulcers. The most common age of occurrence is 6 months to 6 years. Lesions heal spontaneously in 1 to 2 weeks, with the acute phase lasting 7 to 10 days. Treatment usually includes rest, antipyretics, and analgesics. Palliative mouthrinses may be helpful in controlling the oral discomfort. Orabase or petroleum jelly may be used as a protective barrier. Dehydration may be a concern, especially in the younger patient. Information to the caregiver should include explanation of the contagious aspects of this disease. Antibiotics are contraindicated, unless secondary infection is present. Steroids are also contraindicated. Aphthous Ulcers Recurrent aphthous ulcers, or canker sores, are the most common recurrent oral ulcers in the U.S. There are three subtypes: minor, major, and herpetiform, with minor aphthous being the most commonly reported form. 6

Glossitis When the papillae are lost, the surface of the tongue may appear bald and shinya condition called glossitis. Usually a benign condition, it may change in size, location, and appearance, which is then termed wandering glossitis or geographic tongue. Complete glossitis may be associated with a number of disease processes.

Glossitis

Primary Herpetic Gingivostomatitis Primary herpetic gingivostomatitis is caused by an initial infection with the herpes simplex virus Type I

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Aphthous Ulcer

Mild Tetracycline Stain

These ulcers are less than a centimeter in diameter and may occur as a single ulceration or in small groups on nonkeratinized mucosa, including the lateral and ventral aspects of the tongue, floor of the mouth, soft palate, and oropharyngeal mucosa. Major aphthae and herpetiform aphthae each occur in about 10% of cases. They appear as a yellowish white round to oval ulcer with an erythematous halo. The etiology of aphthous stomatitis is unknown. Viral, bacterial, autoimmune, allergic, and nutritional causes have been suspected. Treatment is palliative, and the minor lesions heal in 7-10 days without scarring. Major aphthae, or periadenitis mucosa necrotica recurrens, requires 2-4 weeks to heal and may do so with submucosal scarring. Topical steroids offer some hope for long-term management of recurrence. Discolored Teeth Intrinsic stain of tooth enamel may result from ingestion of excessive amounts of fluoride or prolonged systemic tetracycline administration during critical periods of tooth development. Fluorosis is associated with excessive fluoride ingestion during enamel formation. It is commonly seen as a mild discoloration in the presentation of a white lacy intrinsic stain. Discoloration does not occur from limited tetracycline use (such as from a 7-10 day course of the drug). Crown formation of all teeth is usually complete at age 8, after which tetracycline use will not result in discoloration of teeth.

Moderate Tetracycline Stain

Severe Tetracycline Stain

Severe Tetracycline Stain

Severe Tetracycline Stain

Mild Fluorosis

Moderate Fluorosis

Severe Fluorosis

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Extrinsic stain is usually an accumulation of materials on the enamel surface from foods, medications, or microorganisms. Iron drops cause a black to grey discoloration that is easily removed by the dental professional. Other metal sulfides may also give a similar appearance.

surgical excision with removal of adjacent minor salivary glands to minimize risk of recurrence. Ranula A ranula can appear anytime in the first two decades of life and shows no gender predilection. The ranula will appear unilaterally in the floor of the mouth and is usually larger than a mucocele. Surgical management may be necessary.

Ranula

Stain from Iron Drops

Developmental Conditions Mucocele Ranula Fusion and Gemination Mucocele A mucocele develops when a minor salivary gland duct is injured or severed and the salivary gland secretion spills into the adjacent connective tissue. Granulation tissue forms in response to the secreted mucus and comprises the lining of a cyst like structure. Unlike a true cyst, the cystic space is not lined by epithelium. The most common location is the lower lip. The mucocele is bluish in color if located near the surface and normal in color if deeper in the tissues. Some mucocele are short-lived lesions that burst spontaneously, leaving shallow ulcers that heal within a few days. Many, however, require local

Fusion/Gemination Fusion is the union of two embryologically separate developing teeth. Gemination is the incomplete division of a single tooth bud. Fusion presents clinically as a large bifid crown (with a vertical crease). The geminated crown is smaller but also presents with a vertical crease. Clinically, fusion and germination are usually distinguished by counting the number of teeth in the arch. If there is a deficiency in the normal complement, including the bifid crown, the condition is usually fusion. Typically, fused teeth have two pulp chambers and two canals evident on a dental x-ray. A geminated tooth typically has one pulp chamber and canal.

Mucocele

Fusion

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Ankyloglossia

Gemination

Congenital Conditions Amelogenesis Imperfecta Ankyloglossia Submucous Clefts Congenital Epulis of the Newborn Natal Teeth Hemangioma Amelogenesis Imperfecta Amelogensis Imperfecta characterizes isolated defects of the enamel resulting exclusively from genetic factors, which affect both primary and permanent dentitions. It has been suggested that the anomaly results from a defect in the enamel matrix proteins. It is mainly classified into three types, according to their clinical features and mode of inheritance.

Ankyloglossia Before Frenectomy

Frenectomy

forces on the attached gingival, a simple frenectomy in which the attachment is released may be performed. Submucous Clefts Congenital submucous cleft palate is often undetected on routine physical examination since it occurs beneath the surface of a normal mucosal covering. Often, a submucous cleft palate is associated with a bifid (cleft) uvula. The anatomy of the submucous cleft is variable and includes partial or complete midline cleft of the soft palate musculature concealed by normal mucosa. Bony defects of the hard palate, also concealed by mucosa, vary from subtle notching at the midline of the posterior border of the hard palate to more extensive bony involvement extending further along the midline.

Amelogenesis Imperfecta in the Primary Dentition

Ankyloglossia Ankyloglossia is an abnormally short lingual frenum that is attached near the tip of the tongue. It is present at birth. This binding of the tongue to the floor of the mouth rarely affects speech. Frenectomy may be indicated to correct severe ankyloglossia. If the attachment severely limits normal tongue mobility or results in traumatic

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Congenital Epulis of the Newborn

Bifid Uvula...associated with Submucous Cleft

Natal Teeth Natal teeth (present at birth), or neonatal teeth (erupting shortly after birth), are prematurely erupted teeth. In 85% of the cases, natal or neonatal teeth are normal primary teeth and should be allowed to remain in place unless they are quite mobile.

Submucous cleft palate is frequently asymptomatic, and the patient and clinician are not aware of its presence. Clinical symptoms, seen during early language development, present as hypernasal speech. Consultations with a speech pathologist should be considered. [The removal of adenoids in a patient with normal speech and a bifid uvula should be approached with caution. An undiagnosed submucous cleft palate could be present. Adenoid tissue allows the anatomically compromised soft palate to close off the nasopharynx. Removing adenoids, however, may interrupt closure which would allow air to escape through the nose during speech and produce hypernasal speech.] Congenital Epulis of the Newborn This benign submucosal lesion presents at birth, predominantly in females, and is frequently located in the maxillary anterior area. It is a localized, pedunculated, spongy mass with a smooth surface. A congenital epulis may be the same color as the surrounding mucosa. This condition may cause feeding or respiratory problems. The lesion may spontaneously regress, or excisional biopsy may be necessary. Recurrence is rare.

Natal Teeth

Riga-Fedes disease is an ulcer on the ventral surface of the tongue that is caused by the tongue moving over the sharp edges of natal or neonatal teeth. The infant may experience pain that discourages feeding. The treatment of RigaFede consists of smoothing the sharp edges of the teeth or removing the teeth as a last resort. The ulcers then heal spontaneously.

Irritation of Lingual Frenum

Congenital Epulis of the Newborn

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Riga-Fedes Disease

Epsteins Pearl

Hemangioma Hemangiomas occur within the first decade of life, typically within the first year. A female predilection is evident. The lesions may present as localized or diffuse, red or blue, and flat or nodular in appearance. They are soft and compressible. They blanch when compressed. They are commonly found in the lip, tongue and buccal mucosa. Hemorrhage from trauma is a common problem. Hemangiomas may undergo spontaneous involution or may be successfully treated without recurrence by surgical excision, the use of sclerosing agents, or cryotherapy.

Bohns Nodule

Dental Lamina Cyst A dental lamina cyst is believed to be a remnant of the dental lamina, the embryologic precursors of teeth. It is epithelial in origin. It is found on the alveolar ridge of the maxilla and mandible. No treatment is necessary as the cyst usually disappears after three months.

Hemangioma

Three common conditions seen in the newborn are: Epsteins Pearl Bohns Nodule Dental Lamina Cyst These conditions are benign and generally require no treatment. Epsteins Pearl An Epsteins pearl is a white pearl-like lesion that is found along the midpalatal raphe. It is thought to be an epithelial remnant along the fusion line of the palatal halves. Bohns Nodule A Bohns nodule is a lesion believed to be related to salivary gland remnants. It appears as a raised area located on the lateral portion of the alveolar ridge or between the midpalatal raphe and alveolar crest in the maxilla. 11

Dental Lamina Cyst

Eruption Patterns
The age at which teeth erupt can vary widely. The primary teeth begin to form at 7 weeks in utero with mineralization beginning around the fourth month of fetal development. The eruption of teeth usually occurs symmetrically in each arch, with mandibular teeth erupting before the same maxillary teeth. The sequence of eruption is more important than the timing which varies greatly in both primary and permanent teeth. Variations of 6 months on either side of the usual eruption date may be considered normal for a given child. The first teeth to erupt are the primary mandibular central incisors at the approximate age of 5-8 months, with the maxillary central incisors following a month or two later. A simple way to remember approximate eruption times is the 7 + 4 guideline.

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By the age of 23 months, 16 primary teeth should be present.

At approximately 7 months, the first primary tooth erupts.

23 Months = 16 Erupted Primary Teeth

7 Months = First Primary Teeth Erupt

By the age of 27 months, 20 primary teeth should be present.

By 11 months 7 + 4 there are 4 erupted primary teeth.

27 Months = 20 Erupted Primary Teeth

Eruption Patterns: Permanent Teeth

11 Months = 4 Erupted Primary Teeth

At 15 months, 4 more primary teeth will have erupted for a total of 8 erupted primary teeth.

The first permanent teeth to emerge are the maxillary and mandibular first molars. These molars will erupt behind the most posterior primary teethprimary second molars. The permanent molars are referred to by their anticipated age of eruption. The first molars are called the six-year molars, and the second molars are referred to as the twelve-year molars.

15 Months = 8 Erupted Primary Teeth

By the age of 19 months, the child should have an additional 4 erupted primary teeth for a total of 12 erupted primary teeth.

6-year Molar Eruption Pattern

12-year Molar Permanent Teeth

The first permanent molars usually erupt between 5.5 and 7 years of age. Their eruption may be accompanied by or preceded by the exfoliation of the mandibular central incisors. Between the ages of 6 and 7, the mandibular permanent incisors erupt with the maxillary incisors following at ages 7 through 9.
19 Months = 12 Erupted Primary Teeth

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Eruption Pattern: Permanent Teeth Anterior

The anterior permanent teeth develop behind (lingual or palatal to) the primary teeth, and the permanent premolars (bicuspids) develop beneath and between the roots of the primary molars they replace. Often a bulge on the gingiva can be seen prior to the eruption of a permanent incisor or canine. The bulge is the crown of the erupting tooth.

Eruption Hematomas

Eruption Buldge

Eruption Teething is a natural process that occurs as the tooth penetrates the gum. It may cause increased drooling and the desire to bite or chew on things. There may be mild pain associated with teething, but there is no evidence that high fevers, diarrhea, facial rashes, or sleep problems are caused by teething.

Over-retained Primary Teeth Primary teeth may be retained beyond the normal exfoliation time. One reason for over-retention is the lack of a permanent successor. Another cause of retention is ankylosis, a condition in which the root surface becomes fused to the alveolar bone. The primary teeth most commonly ankylosed are the mandibular primary first and second molars, followed by the maxillary primary first and second molars. For some patients, extraction of the ankylosed tooth may allow for the eruption of a succedaneous tooth. Bruxism has also been identified as a factor in overretention of primary teeth. Disturbances in Exfoliation/Eruption Ectopically erupting permanent teeth follow an abnormal path. This may cause either premature root resorption and early loss of erupted primary teeth or the opposite, when root resorption does not occur and primary teeth are retained. Ectopic eruption may be associated with any tooth. Crowding may be seen in the lower anterior region when the permanent incisors erupt lingual to the primary incisors.

Eruption Patterns
Eruption problems frequently noted and covered in this section are: Eruption Hematoma Over-retained Primary Teeth Disturbances in Exfoliation/Eruption Early or Late Loss of Primary Teeth Eruption Hematoma An eruption hematoma presents as a bluish swelling over an erupting tooth and is usually asymptomatic. The follicle surrounding the erupting tooth becomes filled with blood-tinged fluid. Eruption hematomas usually rupture spontaneously and require no treatment. Treatment is indicated when eating is impaired by the size of the hematoma or if pain is present. 13

Ectopic Eruptions

Early or late loss of primary teeth is sometimes associated with systemic conditions. Cleidocranial dysostosis, Down syndrome,

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hypothyroidism, and hypopituitarism are conditions associated with retention of primary teeth. Conditions associated with premature exfoliation are hypophosphatasia, histiocytosis X, hyperthyroidism and cyclic neutropenia.

Dental Caries and Prevention

Dental Caries The Centers for Disease Control and Prevention reports that caries is perhaps the most prevalent infectious disease in our nations children. Early childhood caries (ECC) can be a particularly virulent form of caries, beginning soon after tooth eruption, developing on smooth surfaces, progressing rapidly, having a lasting detrimental impact on the dentition.

Etiology and Transmission In the most simple terms, the process of dental caries can be illustrated by this Venn diagram: Susceptible tooth Presence of bacteria Access to fermentable carbohydrates and cooked starches Time Bacteria use dietary fermentable carbohydrates (principally sugars and cooked starches) as a substrate for acid production, resulting in a lowering of the pH of the area. Species of Streptococcus and Lactobacillus are most often s s implicated in the caries process. Streptococcus mutans acquisition is usually s associated with the eruption of the first primary s teeth. However, S. mutans may appear as an oral microbe in the infant prior to the eruption of primary teeth primarily through direct transmission between caretaker and child. Transmission can be delayed/prevented by the initiation of a prevention program for caregivers who have high levels of S. mutans that includes meticulous oral s hygiene.

Severe ECC (Early Childhood Caries)

Newer theories on the etiology of tooth decay and transmission of causative organisms highlight the fact that dental caries is an infectious and communicable disease. This review of the caries process covers: Etiology and Transmission Patterns of Decay Caries Risk Assessment Anticipatory Guidance

Streptococcus Mutans Transmission

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The Caries Process Enamel is composed of mineralized crystals in an organic matrix. This unique structure provides channels through which minerals, such as calcium and fluoride, and acids can flow. We no longer think of dental caries as a simple, uncontrollable, linear progression from acid demineralization to a frank clinical lesion. We now believe the caries process is dynamic and involves demineralization and remineralization.

Remineralized Enamel (Note: Intact surface layer and remineralization area.)

Remineralization represents the opposite reaction. During remineralization, mineral is redeposited in the subsurface lesion. Fluoride, even in low concentrations, can enhance the remineralization of enamel and may actually result in a crystal structure that is more caries resistant.
Enamel Structure

Normally, equilibrium exists between mineral loss (demineralization) and mineral gain (remineralization). Demineralization occurs when acid lowers the pH at the tooth surface. This causes calcium, phosphate, and other minerals to diffuse out of the enamel and creates a subsurface lesion.

In this process of demineralization and remineralization, enamel caries can actually be reversed providing the outer surface layer of the enamel is still intact. Once the outer surface layer is lost, the potential for remineralization is also lost, and the tooth must be restored. Role of Saliva The flow, dilution, buffering, and remineralizing capacity of saliva are also recognized to be critical factors that affect, and in some ways regulate, the progression and regression of the disease. If the oral environment is balanced and favorable, saliva can contribute to strengthening of the tooth by supplying the components to help build strong apatite structure.

Demineralized Enamel

Subsurface Lesion

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Patterns of Decay Three basic patterns of decay will be reviewed in this section. These patterns are: Early Childhood Caries Pit and Fissure Caries Smooth Surface Caries Early Childhood Caries Early Childhood Caries may initially affect the primary maxillary incisors of children who are routinely given a nursing bottle containing a fermentable carbohydrate at night or nap times, or who breast-feed (at will) after teeth have erupted. Frequent, non-mealtime use of sippy cups containing beverages other than water is known to have a similar affect.

Additionally, upper primary incisors are in a saliva deficient area and therefore are more susceptible to acid attack. The nipple of the baby bottle and the infants tongue cover the mandibular anterior teeth, which are also wet by the major salivary glands. Lower anterior teeth are rarely affected unless the decay becomes rampant. If detected early, further demineralization can be minimized and may be reversed by modifying diet, dietary habits, oral hygiene practices and introducing fluoride. Pit and Fissure Caries Dental caries can readily begin on biting surfaces of posterior teeth, in pits, fissures and defects of the enamel. The enamel at the base of pits and fissures is frequently thin. Additionally, the plaque collected in these areas is not easily removed by normal oral hygiene measures.

Pit and Fissure Caries

Smooth Surface Caries Smooth surface caries occur where there is no pit, groove, or other fault on a tooth. They occur in areas where bacterial plaque collects, such as between teeth, along the gumline, and other difficultto-clean areas.

Smooth Surface Caries

Caries Risk Assessment

While a significant percentage of the U.S. child population remains caries-free, a caries risk assessment for each child patient should be a part of the childs overall health assessment. Components of a caries risk assessment include: Clinical Examination Dental History Medical History 16
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Early Childhood Caries

As the child sleeps, pools of fermentable liquid can collect around the teeth, especially the maxillary incisors, which can initiate the decay process.

Clinical Examination A dental examiner should evaluate the anatomical structure of the biting surfaces of posterior teeth. Stained pits and fissures indicate increased risk of caries. White spot lesions and visible plaque are additional indicators of high caries risk.

breastfeeding are behaviors that increase a childs risk for developing early childhood caries. Unsupervised feeding on demand during sleeptime is also a high caries-risk behavior. 4. Family Dental History A family history of dental caries increases a childs risk for caries. The caries history of the mother or the primary caregiver should be carefully evaluated to determine if the child has an increased risk for caries. The caregivers knowledge of dental health and attitude toward dental care should also be assessed. Children from lower socioeconomic families have a higher risk for developing dental caries. 5. Oral Hygiene At home oral hygiene and plaque control remain essential elements for oral health. The proper use of manual or powered toothbrushes, toothpaste and floss needs to be determined. In children, thorough oral hygiene procedures should be performed at least once daily, preferably twice, with parental supervision. Visible plaque on anterior teeth is a high-risk indicator for caries.

Dental Examination

Dental History 1. Use of Fluoride This assessment should include the dosage and frequency of use of fluoride from various sources such as water, dietary supplements, rinses, toothpastes and other dietary sources of fluoride like beverages and processed food. The primary water source (which may not be the childs home) should be identified and assessed for fluoride. 2. Dietary Habits Types, consistency, and frequency of solid and liquid food intake should be evaluated for cariogenic potential. On-demand bottle feeding with a fermentable carbohydrate, on-demand breast-feeding and frequent consumption of nonmealtime snacks daily increase the caries risk by increasing the amount of time oral acid is formed and therefore increasing the chance for enamel demineralization. 3. Sleeptime Habits Allowing a child to fall asleep with a bottle containing a fermentable carbohydrate or while

Oral Hygiene Habits

Medical History There are still pediatric medications containing sucrose that may be administered at bedtime. Additionally, patients who are regularly taking medications for chronic conditions may need to be on a more intensive prevention program. Children undergoing radiation therapy may have reduced salivary flow which warrants the highest attention toward preventing caries, especially if they are also taking medication that contains sucrose. Additionally, children with special health care needs are at increased risk for oral diseases including caries. An accurate and up-to-date medical history is essential for correct diagnosis and effective treatment planning.

Sleeptime Habits

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Nonnutritive Sucking Sealants

Medications

Caries and Infection If left untreated, a carious tooth surface typically will continue to demineralize. Once the demineralization process has exposed the pulp, which is the neurovascular bundle at the center of each tooth, an infection can result. An untreated dental abscess can lead to the rapid development of cellulitis. Cavernous sinus thrombosis and Ludwigs angina pose life-threatening complications, which can also result from an untreated dental abscess.

Initial Dental Visit The American Academy of Pediatric Dentistry recommends that every infant should receive an oral health risk assessment from his/her primary health care provider or qualified health care professional as early as 6 months of age, 6 months after the first tooth erupts, and no later than 12 months of age. This initial visit should consist of the following: Assessing the patients risk of developing oral disease. Providing education on infant oral health Evaluating and optimizing fluoride exposure

Initial Dental Visit

Facial Cellulitis...Due to Untreated Dental Abscess

Anticipatory Guidance Drooling, teething, mouthing objects, nonnutritive sucking, sequence of tooth eruption, and injuries to newly erupted primary incisors as children learn to walk are just a few of the subjects that can be covered in helping parents anticipate potential oral health problems. Appropriate use of the nursing bottle, adequate fluoride exposure, and parents cleaning newly erupted teeth are guiding concepts that can help infants and toddlers toward good oral health. Subjects covered in this section are: Initial Dental Visit Fluoride Diet Oral Hygiene

Parents or caregivers should establish a dental home for infants by the childs first birthday. The dental home is inclusive of all aspects of oral health that result from the interaction of the patient, parents, non-dental professionals, and dental professionals. Establishment of the dental home is initiated by the identification and interaction of these individuals, resulting in a heightened awareness of all issues impacting the patients oral health. This provides timecritical opportunities to implement preventive health practices and reduce the childs risk of preventable dental/oral disease. Should treatment be required, appropriate recommendations and referrals can be made at that time. Fluoride Dietary fluoride is available in fluoridated water. In areas where the water does not contain optimal levels of fluoride, after careful consideration of the other dietary sources of fluoride and the childs age (i.e., stage of dental development), fluoride supplements may be prescribed.

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ADA Recommended Supplemental Fluoride Dosage Schedule

Fluoridation of community water supplies began in1945. Water fluoridation has been proven to be the most cost effective way to reduce caries rates. Drinking fluoridated water from infancy can reduce caries incidence by up to 50%. Over half of the United States population drinks fluoridated water.
Fluorosis

Optimal exposure to fluoride is important to all dentate infants and children. Caution is indicated in the use of all fluoride-containing products. Decisions concerning the administration of additional fluoride are based on the unique needs of each patient. Local or state departments of health or a local water authority can determine the fluoride concentration of community supplied water. Private water sources, such as wells, should be analyzed for fluoride content. The optimum fluoride concentration in drinking water is approximately 1.0 part per million. The table shows the current fluoride supplement recommendations. Although infants can be given fluoridated water from birth, fluoride supplements are no longer recommended for any infant less than age 6 months. When fluoride is ingested in quantities exceeding the recommended systemic dose, a condition known as fluorosis (primarily a cosmetic concern) may result. Fluorosis represents an alteration in the formation of tooth enamel caused by excessive systemic fluoride.

The characteristic clinical appearance can range from mild white discoloration of the enamel to severe brown and white malformation of the enamel. Careful monitoring of all sources of systemic fluoride can prevent fluorosis. Fluoride supplements are available as drops, chewables, tablets, and combined with vitamins. All forms come in 0.25 mg, 0.5 mg, and 1.0 mg doses. Topical Fluoride The use of topical fluorides may result in a 20% to 40% reduction in caries. Topical application of fluoride is available via: Professionally applied topical fluoride treatment Over-the-counter rinses for home use Prescription rinses and gels for home application Fluoride-containing toothpastes Over-the-counter fluoride mouthrinses are not recommended for preschool aged children. Fluoride mouthrinses or brush-on gels may be recommended for school-aged children with

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active caries or at high risk for caries. Indicators of high risk include: orthodontic/prosthodontic appliances reduced salivary function inability to clean teeth properly dietary risks siblings with caries high oral levels of cariogenic bacteria Over-the-counter rinses are designed for daily use. Higher concentration fluoride prescription rinses and gels are designed for weekly use. Ingestion of fluoridated toothpaste carries an increased risk of fluorosis. This risk must be weighed against the benefit of caries prevention in determining the use of a fluoridated toothpaste by a child. A very small amount of toothpaste, equal to the size of a pea, should be wiped onto the toothbrush by the caretaker for very young children. Fluoride products should be kept in childproof storage areas. This includes not only supplements but toothpastes, fluoride rinses, and gels. Diet All solid and liquid foods containing fermentable carbohydrates are potentially cariogenic (causing caries). Acid-forming bacteria, such as cariesproducing Streptococcus mutans, begin the

immediate breakdown of sucrose from food, potentially contributing to dental caries. Sugars on the tooth surfaces are converted to acid within seconds of ingestion. The acid acts to demineralize the tooth. Left undisturbed, the acid produced from the ingestion of a sugar can remain in the oral cavity up to 2 hours. During this acid attack, the pH level of plaque drops from a normal range of 6.2-7.0 down to a pH of 5.2-5.5, the level at which demineralization can occur. Consumption of caries-producing solid and liquid foods will lower the oral pH to a level that makes the enamel susceptible to caries. These frequent exposures can lower the pH to demineralizing levels for several hours per day. The texture of foods, likewise, influences the length of time demineralization can occur. Foods that are more retentive and slower to dissolve will remain on the tooth surface for a longer time. After the eruption of the first primary tooth, prevention of ECC is possible by restricting bottle/breast feeding to normal meal times and not allowing the infant to feed ad libitum or while sleeping. In order to eliminate or reduce caries risk in their infant or young child, caretakers should understand the relationship between diet and dietary habits and dental caries. The

Diet and Dental Caries

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caregiver should be advised to establish a pattern of three regular meals a day. In between-meal snacks should be limited and be foods of high nutrient density with low cariogenicity. Additionally, incorporating more fibrous and lessretentive foods, such as uncooked crisp fruits and vegetables, will help stimulate salivary flow and promote the remineralization process. Oral Home Care This section will review: Toothbrushing and Flossing Nutrition Nonnutritive Sucking Habits Caretakers should be counseled as to their role in infant oral hygiene. Information and guidance should be made available to plan a daily routine of plaque removal. This can be incorporated into the daily routine at bath time.
Toothbrushing Technique

Oral Hygiene should begin with the eruption of the first tooth

in a circular motion. The occlusal surfaces can be brushed with a back-and-forth motion. Each area brushed should slightly overlap the previous section. Positioning the child to assure stabilization and ease of access to the oral cavity can be accomplished by using a changing table or by placing the childs head in the lap of the caregiver. As the infant gains more control of the neck muscles, a more face-to-face approach may be attempted. Until that time, support for the head and neck are vital. By cradling the head against the caregivers chest, one hand can be free to support the chin and one hand free for brushing.

Gingivitis

In the presence of inflammation, a color change can be noted in the gingival tissues from pink to red, accompanied by a loss of stippling, and bleeding. The most common cause of gingivitis is undisturbed, accumulated plaque at the gingival third of the tooth. Gingivitis is reversible. Instituting consistent and thorough daily plaque removal, the gingiva will return to good health. Toothbrushing Cleansing the infants teeth as soon as they erupt with either a washcloth or soft brush will help reduce bacterial colonization. The use of a systematic approach should be encouraged to ensure that all surfaces of all erupted teeth are cleaned. The bristles of the brush should be angled toward the gingival margin, with light pressure applied

Toothbrushing Technique: Position the Child for Optimal Stabilization and Intraoral Visibility

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The back of the brush or a finger can be used to retract the cheek and tongue for access to posterior teeth. Finger retraction of the lip will provide access to anterior areas. Children will show signs of wanting to clean their own teeth by the age of 24 months. The finemotor skills necessary for the child to adequately perform this activity are not yet developed at this age. The caretaker will still need to be on hand to coach, assist, and complete the procedure.

may help the child visualize the areas that need to be cleaned along with the effort and brush manipulations necessary to accomplish this task. Allowing children to choose their own toothbrush from an assortment of soft nylon-bristle brushes may stimulate their interest. Child toothbrushes are available with age-appropriate bristles and handle designs. Setting aside special times of day for brushing, likewise, can help establish the importance of oral hygiene.

Supervised Toothbrushing

Toothbrushes Designed for Children

Toothpaste can be used as a means to deliver fluoride to the tooth surface. The use of a fluoridated toothpaste should always be supervised in this age group. For those under two years old, a smear of fluoridated toothpaste is recommended by the American Academy of Pediatric Dentistry. A very small amount of fluoridated toothpaste, equal to the size of a pea, should be wiped onto the toothbrush by the caretaker for children over the age of two. Caution should be taken to prevent the swallowing of toothpaste during critical periods of enamel formation. At age 3 to 4, a disclosing tablet or solution can be used with supervision. The stained plaque

Flossing Primary incisor teeth may be spaced far enough apart that they do not require flossing. When adjacent teeth are touching, dental floss should be used to clean interproximal (in between) surfaces of teeth. Gentle pressure should be used during flossing to prevent injury to the gingival tissues as floss is guided between the teeth. Again, coaching, assistance, and completion of the task by the caretaker will be necessary. A flossing aid may provide the caregiver easier access to the posterior teeth. Flossing is important to prevent interproximal caries and gingivitis.

Flossing Can be Initiated as Needed

Early Childhood Caries Counseling caretakers regarding feeding practices and daily tooth cleaning for infants should include information on Early Childhood Caries (ECC). ECC is a particularly virulent
Disclosed Plaque

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form of caries that can develop when an infant is provided a bottle of formula, milk, or sugared liquids for at-will feedings and/or at sleep times. Sugared liquids remain in the mouth for hours creating an acid environment that enhances enamel demineralization. The maxillary incisors are the first teeth affected, usually by 18 to 20 months of age. Because children who experience ECC have a greater probability of subsequent caries development in both the primary and permanent dentitions, aggressive preventive and therapeutic measures often are necessary. Alternative Restorative Treatment (ART) and stainless steel crowns (SSC) should be considered as treatment options. Without early caries detection and therapeutic intervention, extractions may be indicated. Sedation or general anesthesia often is a necessary adjunct in guiding the behaviors of young children who require dental treatment. Nonnutritive Sucking Habits Habits such as finger or thumb sucking and pacifier use are a normal part of neonatal development. Digit sucking habits are thought to arise from the rooting reflex. Nonnutritive sucking habits are a source of comfort to most infants.

Changes in Dentition: Due to Nonnutritive Sucking Habits

on the intensity, frequency, and duration of the habit. These changes include increased overject (protrusion of the maxillary incisors), decreased overbite (open bite) and posterior crossbite (from a narrowing of the palate). In children between 4 and 6 years old, nonnutritive oral habits are no longer considered normal and may be viewed in some cultures as socially unacceptable. Intervention may be required with success depending on the childs readiness to discontinue the habit. Habit discouragement will usually require six months of treatment. Pacifiers should never be attached around the childs neck. Use of a sweetener on the nipple should be discouraged. Pacifiers must also be 23
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Nonnutritive Sucking Habits

The rooting reflex will start to dissipate at 7 months of age; the sucking reflex will be replaced with other feeding skills by 12 months of age. Spontaneous abandonment of oral habits usually occurs between 2 and 4 years of age. Changes in the primary dentition can occur when nonnutritive sucking continues, depending

Dental Sealants

Before

After

90 % after 10 or more years. Sealants are easily repaired or replaced if necessary.

Pacifier Use

Orofacial Trauma
Injuries to the Primary and Permanent Dentition As in any injury, an adequate history is essential for proper diagnosis and treatment. Before initiating any treatment, a systemic and neurological assessment of the child should be completed. The childs general health history should be reviewed. Depending on the nature of the injury, adequate tetanus immunization should be ensured. Clinical examination should rule out major systemic injury and include facial and neck palpation to determine if any injuries have occurred to bones, joints, or soft tissues. Intra-oral examination should include the injured tooth or tissues as well as all surrounding soft and hard oral tissues for possible secondary injuries. Radiographs are requested based on clinical findings. Child Abuse (Non Accidental injuries) The examiner should always be alert to the potential for child abuse in injury cases and cognizant of the legal responsibility to report any suspicions to the proper authorities. Physical abuse is usually recognized by the pattern of injury and/or its inconsistency with the history related. Bruises, welts, fractures, burns, and lacerations are commonly inflicted physical injuries. Head, face, and neck injuries occur in more than half of the cases of child abuse. Sexual abuse may be suspected when there is palatal bruising or a torn frenum attachment. While the oral cavity is a frequent site of sexual 24

kept clean and replaced when worn. Children should not be allowed to run or play with their pacifiers in their mouths. The ability to gradually discontinue the use of the pacifier by limiting the time it is available to the child is one method for gradual elimination of a pacifier habit. Nonnutritive sucking of a pacifier is an easier habit to break than nonnutritive digit sucking. Dental changes created with prolonged pacifier use are similar to those of finger or thumb sucking habits, though protrusion of the anterior incisors may not be as pronounced. Sealants Any primary or permanent tooth with pits and fissures judged at risk for caries would benefit from sealant application. Sealant placement on those teeth with highest risk will give the greatest benefit. High-risk pits and fissures should be sealed as soon as possible. Low-risk pits and fissures may not require sealants. Caries risk, however, may increase due to changes in patient habits, oral microflora, or physical condition, and unsealed teeth might subsequently benefit from sealant application. Dental sealants are available in an opaque, tinted, or clear form. Tinted and opaque sealants are easier to detect at subsequent dental examinations. Studies incorporating recall and maintenance have reported sealant success levels of 80 % to

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abuse in children, visible oral injuries or infections are rare. Unintentional or accidental injuries to the mouth are common and must be distinguished from abuse based on whether the history, including the timing and mechanism of injury, is consistent with the characteristics of the injury and the childs developmental capabilities. Injuries to Primary Teeth The greatest incidence of trauma to the primary dentition occurs at 2 to 3 years of age, when motor coordination is developing. The most frequently injured teeth are the maxillary incisors.

Displaced Primary Teeth

not contacting the permanent tooth bud may be allowed to re-erupt. Immediate extraction may be indicated if the radiograph reveals that the intruded tooth contacts the permanent tooth bud. Periodic reevaluation of the intruded tooth is prudent. Avulsion Avulsion is complete displacement of the tooth from the socket. Avulsed primary teeth should not be replanted. In the primary dentition, the maxillary anterior region is at low risk for space loss unless the avulsion occurs prior to the eruption of the canines. To satisfy parental concerns for esthetics or to return a loss of oral or phonetic function, fixed or removable appliances can be fabricated. An avulsed permanent tooth should be replanted except when replanting is contraindicated by the childs stage of dental development (risk for ankylosis where considerable alveolar growth has to take place) or compromising medical condition or by compromised integrity of the avulsed tooth or supporting tissues. An avulsed permanent tooth should be replanted as soon as possible and then stabilized in its anatomically correct location by a dentist using a flexible splint. The longer the tooth is out of the mouth, the poorer the prognosis. Do not handle the root surface, but do rinse the tooth quickly under running water to remove foreign material.

Injury to Primary Incisor

Injuries to primary teeth include fracture, displacement, and avulsion. Small fractures of primary teeth may leave a roughened tooth surface and may require smoothing. If the fracture exposes the pulp, pulp (or endodontic) treatment and stainless steel crown (SSC) maybe required for restoring the fractured tooth. Tooth fractures must be assessed radiographically to determine if root fractures are present.

Fractured Primary Tooth

Displacement injuries need to be evaluated to determine the childs occlusion and the proximity of the injured tooth to the permanent tooth. An extruded primary tooth that interferes with a childs ability to bite (or occlude) should be repositioned or extracted. An intruded tooth

Avulsion Site

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Avulsed Tooth

Permanent teeth that have been extruded or luxated laterally need to be repositioned as soon as possible to optimize healing of the periodontal ligament and neurovascular supply. They should be stabilized by splinting in their anatomically correct position. Mature permanent teeth that have been displaced or loosened may undergo pulpal necrosis due to associated injuries to the blood vessels at the apex and, therefore, must be followed carefully. After trauma, the permanent tooth should be evaluated for mobility before splinting is considered. Treatment may also include orthodontic repositioning. Parents should be advised that any injury to a permanent tooth may result in pulpal necrosis. Periodic reevaluation is indicated.

Splinted Avulsed Tooth

6 Month Follow-up

If it is not possible to reimplant the tooth immediately, it should be stored in a medium that will help maintain the vitality of the periodontal ligament fibers on the roots surface. Transportation media for avulsed teeth include (in order of preference): Viaspan, Hanks Balanced Salt Solution, cold milk, saliva, physiologic saline, or water. Tetanus prophylaxis and antibiotic coverage and pulp therapy should be considered. There are possible contraindications to tooth replantation. Examples are immunocompromised status, severe congenital cardiac anomalies, severe uncontrolled seizure disorder, severe mental disability, severe uncontrolled diabetes, and lack of alveolar integrity.

Luxated Permanent Tooth

Intruded Permanent Teeth

Displaced Permanent Teeth Trauma can result in the displacement of teeth into the bone (intrusion), partially out of the socket (extrusion), or in another direction (lateral luxation). For intruded permanent teeth with immature root formation, the objective is to allow for spontaneous eruption. Intruded permanent teeth with complete root formation may be repositioned surgically or orthodontically. 26

Extruded Permanent Teeth

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Dental Fractures Fractured permanent teeth should be evaluated as soon as possible for pulpal exposure. After controlling hemorrhage, exposed healthy pulp tissue is covered with a material such as calcium

Frenum Laceration

Lacerated Lip

Fractured Permanent Tooth

lacerations when they fall. Lacerated lips may contain tooth fragments if a tooth is also fractured in the injury. Fragments should be removed before suturing. Wound management consists of hemorrhage control, cleansing, and sutures as indicated. Antibiotics are recommended for through and through lacerations. The risk of severe dental and facial injuries can be reduced significantly when carefully fitted mouthguards and facemasks are worn when participating in sporting activities. Routine use of helmets (e.g. for bicycling and skateboarding), seat belts, and age-appropriate car seats also can help decrease risk of orofacial injuries.

hydroxide or mineral trioxide aggregate (MTA) prior to placing a restoration that seals the tooth from microleakage. Periodic evaluation of pulpal condition is required. Soft Tissue Trauma Soft tissue trauma may include lacerations to the lips, frenum, tongue, cheeks, and hard and soft palate. Frenum lacerations are common in toddlers who fall when learning to walk and are also associated with forced feeding. Children who ambulate while holding rigid objects in their mouths are at risk for hard and soft palate

Laceration of Tongue

Prevention of Dental Trauma

Soft Tissue Trauma of the Palate

Oral Electrical Injuries Oral electrical injuries in children are usually the result of a toddler sucking or biting into a live electrical cord. The commissure of the mouth will show extensive damage from the electrical current arcing, resulting in gray-white tissue with elevated red margins. Bleeding does not usually

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Recent Electrical Burns

Commissure Splint Scarred Commissure Burn

occur at this stage. Minor pain and swelling usually result. Emergency treatment is based on the extent of the wound. Debridement, systemic antibiotics, and a tetanus booster should be considered. Parents should be cautioned that the eschar will slough in 5-7 days and that significant bleeding could occur at this time. A commissure splint is fabricated within days of the injury and is worn for up to 12 months following the burn to prevent microstomia secondary to wound contraction.

Commissure Splint in Place

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Course Test Preview

To receive Continuing Education credit for this course, you must complete the online test. Please go to www.dentalcare.com and find this course in the Continuing Education section. 1. A diastema is NOT considered part of normal dental development: a. After eruption of the permanent canines b. In six-year-olds with a diastema in excess of 3 mm c. In eight-year-olds with a diastema in excess of 3 mm d. During the primary dentition Fungiform papillae: a. Are found on the lateral border of the tongue b. Are the most numerous papillae c. Are singular knoblike projections d. Appear as parallel slits The transverse ridges, located at the anterior portion of the hard palate, are known as: a. Maxillary arch b. Rugae c. Alveolar bone d. Incisive papillae Recurrent Aphthous Ulcer is: a. A common acquired condition b. A congenital condition c. A developmental condition d. Characterized by raised, white, curd like plaques Systemic symptoms of fever, malaise, and cervical lymphadenopathy are associated with: a. Primary herpetic gingivostomatitis b. Aphthous ulcers c. Mucocele d. Hemangioma At a. b. c. d. what age does mineralization begin for primary teeth? 8 months 7 weeks 4 months in utero 13 weeks

2.

3.

4.

5.

6.

7.

Early or late loss of primary teeth is sometimes associated with which condition? a. Glossitis b. Hypothyroidism c. Candidiasis d. Fluorosis Discoloration of teeth will not occur from tetracycline administration: a. Between the ages of six-months to four-years b. Between ages of four-years to eight-years c. With long-term use by any child d. After crown formation is complete

8.

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9.

Which of the following is true? a. Gemination and fusion can be distinguished only by dental x-rays b. Fusion is the union of two separate developing teeth c. Geminated teeth have two pulp chambers, two canals d. Fused teeth have one pulp chamber, two canals This condition is frequently undetected and causes hypernasal speech: a. Congenital epulis of the newborn b. Submucous cleft c. Mucocele d. Fusion The Caries Process is: a. Demineralization and remineralization b. Fermentable carbohydrates as fuel for bacteria collecting around the tooth surface producing lower pH and initiating the decay process c. High pH causing the deposit of calcium and other minerals d. Low pH causing calcium, phosphate and other minerals to diffuse out of the enamel Over-the-counter fluoride mouthrinses are: a. Not recommended for preschool-aged children b. Recommended for all children c. Recommended only for children with mild to moderate caries d. Designed for weekly use Spontaneous abandonment of oral habits normally occurs at: a. 12 months b. 1-2 years of age c. 2-4 years of age d. 4-6 years of age Caregiver counseling should include: a. No sugared liquids at sleep times b. Daily teeth cleaning c. No at-will feeding with formula, milk or sugar liquids d. All of the above An avulsed permanent tooth should be: a. Placed in a dry - low humidity bag or container b. Scrubbed clean and kept sterile until reimplantation can be assessed c. Rinsed off with water and placed back in socket or stored in milk d. Wrapped in a wet towel or cloth Repositioning, splinting, and routine pulpal evaluation should be considered for: a. Laterally luxated permanent teeth b. Intruded immature permanent teeth c. Avulsed primary teeth d. None of the above In soft tissue trauma antibiotics are recommended for through and through lacerations: a. True b. False

10.

11.

12.

13.

14.

15.

16.

17.

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18.

Risk for dental injuries occurring while playing sports can be decreased: a. Can not be decreased b. With the use of a carefully fitted mouthguard c. Without proper training and instruction d. If contact sports are not pursued until the age of 10 A commissure splint after an electrical burn is recommended to: a. Ensure proper cosmetics during healing b. Prevent excessive scarring c. Be worn for a maximum of six months d. Prevent microstomia secondary to wound contraction

19.

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References
1. Pinkham JR, Casamassimo PS, McTigue DJ, Fields HW, Nowak AJ. Pediatric Dentistry: Infancy Through Adolescence, 4th edition. St. Louis, MO: Elsevier Saunders, 2005. 2. McDonald RE, Avery DR, Dean JA. Dentistry for the child and adolescent. Mosby 8th ed. 2004. 3. DHHS. Oral Health in America: A Report of the Surgeon General. Rockville, MD: US DHHS, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. 4. Hale KJ; American Academy of Pediatrics Section on Pediatric Dentistry. Oral health risk assessment timing and establishment of the dental home. Pediatrics. 2003 May;111(5 Pt 1):1113-6. 5. AAPD. Policy on the Dental Home. Pediatr Dent 26(7):18-19, 2004. 6. AAPD. Clinical guideline on periodicity of examination, preventive dental services, anticipatory guidance, and oral treatment for children. Pediatr Dent. 2004;26(7):81-3. 7. Welbury RR. Pediatric dentistry. Oxford [England] New York: Oxford University Press, 1997. 8. Curzon MEJ. Roberts JF, Kennedy DB. Kennedys pediatric operative dentistry. 4th ed. Oxford; Boston: Wright, c 1996. 9. Hall RK. Pediatric orofacial medicine and pathology. 1st ed. London; New York: Chapman & Hall Medical, 1994. 10. Mathewson RJ, Primosch RE, Morrison JT. Fundamentals of pediatric dentistry 3rd ed. Chicago: Quintessence Books, c 1995. 11. Roberts GJ, Longhurst P. Oral and dental trauma in children and adolescents. Oxford; New York: Oxford University Press, 1996.

About the Author

Prashant Gagneja, DDS, MS Dr. Gagneja is an Assistant Professor and Interim Chairman of the Department of Pediatric Dentistry at the Oregon Health & Science University School of Dentistry (OHSU). Dr. Gagneja joined OHSU in 2003. Prior to joining OHSU, Dr. Gagneja was associate professor and interim chairman of pediatric dentistry and orthodontics at the Sri Guru Ram Dass Institute of Dental Sciences and Research in Amritsar, PB, India. Dr. Gagneja also was a visiting professor at the Baba Farid Medical University in Faridkot, India. Dr. Gagneja completed his undergraduate degree in dental surgery at Punjabi University in Patiala, PB, India, and his masters in dental surgery (pediatric and preventive dentistry) at Guru Nanak Deve University, Amritsar, PB, India. He also received a certificate of specialty in pediatric dentistry from the University of Medicine and Dentistry of New Jersey in Newark. Dr. Gagneja is a member of the American Academy of Pediatric Dentistry, the American Dental Education Association, and the American Dental Association. He has won numerous awards and is a continuing education speaker for pediatric dentistry. Prashant Gagneja, DDS, MS Interim Chairman & Asst. Professor Dept. of Pediatric Dentistry OHSU School of Dentistry 611 SW Campus Dr. Portland, OR 97239-3097 E-mail: gagnejap@ohsu.edu

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